- Email: [email protected]
Exploring patient experience and understanding of Chlorhexidine Gluconate preoperative washes: A cross-sectional survey
Infection, Disease & Health (2017) 22, 51e56
Available online at www.sciencedirect.com
ScienceDirect journal homepage: http://www.journals.elsevier.com/infectiondisease-and-health/
Research
Exploring patient experience and understanding of Chlorhexidine Gluconate preoperative washes: A cross-sectional survey Alannah L. Cooper a,b,*, Janie A. Brown c, Julie Salathiel a, Sally Gollner a, Fiona Childs a, Elizabeth Boucher a, Danielle Morris a, Brian Riggall-Southworth a, Lyn Balinski a, Kaylene Riches a, Toni Dennis a, Felicity Timmings a a
St John of God Subiaco Hospital, Australia Fiona Stanley Hospital, Australia c Curtin University, Australia b
Received 6 January 2017; received in revised form 23 February 2017; accepted 23 February 2017
Available online 31 March 2017
KEYWORDS Patient care; Surgery; Chlorhexidine; Patient compliance; Survey
Abstract Objectives: To explore patient experience, understanding and compliance with using Chlorhexidine Gluconate (CHG) preoperative washes. Methods: A cross-sectional survey was conducted over a ten week period with adult inpatients who had undergone a surgical procedure at the study hospital. The survey consisted of 17 questions which participants self-completed. Closed and open-ended questions were included in the survey to allow both statistical and thematic analysis. Results: A 74% (n Z 194) sample response rate was attained. The sample obtained was representative of the wider hospital surgical patient population. Although 85% (n Z 159) of participants reported they used CHG prior to their surgical procedure only 63% (n Z 101) used the wash the recommended two times. Across all age groups in the survey 20% (n Z 36) of participants reported they received too little information about CHG washes. Open-ended questions revealed three key themes; lack of information, issues with time or access and inconsistencies across the hospital. Conclusion: This project revealed the current experience of patients undergoing surgery in relation to preoperative washing. Lack of information regarding CHG, issues with timing of information and access, as well as inconsistencies between different surgical specialities within
* Corresponding author. Nursing and Midwifery Research, St John of God Subiaco Hospital, 12 Salvado Road, Subiaco, Western Australian, 6008, Australia. E-mail address: [email protected] (A.L. Cooper). http://dx.doi.org/10.1016/j.idh.2017.02.002 2468-0451/ª 2017 Australasian College for Infection Prevention and Control. Published by Elsevier B.V. All rights reserved.
52
A.L. Cooper et al. the hospital were identified as barriers to participants using CHG. These are areas which could be targeted with a suite of interventions which aim to provide patients with clear, consistent information in a timely manner. ª 2017 Australasian College for Infection Prevention and Control. Published by Elsevier B.V. All rights reserved.
Highlights A cross-sectional survey of patient experience of CHG preoperative washes. Issues were discovered with the number of CHG applications, access, lack of information and understanding. By identifying issues patient’s encounter targeted interventions can be implemented to improve understanding and compliance.
Introduction
Background
Preoperative washing has been part of patient care for several decades and many research studies have been conducted examining the effectiveness of the various types of preoperative washes [6,7,13]. There has been a move away from recommending the use of CHG and other antiseptic washes with claims that the use of soap and water is equally effective [5,15], however the use of antiseptic washes remains commonplace [1,13]. Chlebicki et al. [5] conducted a meta-analysis which included 16 studies and found no appreciable benefit of CHG washes in the prevention of SSI. However, of the 16 studies included in the meta-analysis only four were published from 2009 onwards. The other 12 studies were published between 1979 and 1992 and as Chlebicki et al. [5] acknowledge most of the studies did not give details of a standardised process for CHG application and better designed trials are needed to determine the effectiveness of CHG on SSI rates. Systematic reviews synthesizing the results of recent research studies have debunked the claims of older studies that soap and water are just as effective at reducing bacterial colonisation as antiseptic washes [9]. Numerous recent studies have shown the effectiveness of CHG antiseptic washes in reducing SSI for and treatment of the colonisation of Staphylococcus aureus when used in conjunction with nasal screening [3,4,10,11]. Tanner et al. [13] raised concerns over UK national guidelines which did not support preoperative washing to reduce SSI and conducted a randomised control trial in healthy volunteers which demonstrated that CHG was significantly more effective than soap in reducing colony forming units. Similarly, Edmiston et al. [7] have raised the concern that organisations such as the Association of Perioperative Registered Nurses (AORN) and the Centers for Disease Control and Prevention (CDC) are basing recommendations on out-dated, methodologically weak research and not utilising evidence from more recent studies. These more recent studies which have a standardised process for CHG application demonstrate the potential benefits of CHG. A focus on how to facilitate the optimal use of CHG by patients as well as large scale randomised control trials with clear standardised processes are needed to determine the true effectiveness of CHG washes [7].
During the financial year of 2015/2016, 22,990 inpatient surgical procedures were performed at the study hospital. The study hospital policy states: “Where possible, elective surgical and obstetric patients (excluding paediatrics) should have at least (1) preoperative antiseptic shower prior to surgery, including hair washing if appropriate.” [12]; p. 3). Because the policy is vague and provides limited direction, it is standard care at the study hospital for the preadmission clinic to advise all patients admitted on the day of their elective surgery to undertake two preoperative CHG washes, one the night before surgery and one the morning of surgery. In addition to the verbal instructions around CHG washes a written instruction sheet is also emailed to patients. This measure was advised because preadmission clinic nurses were aware of the evidence reporting that CHG washes have been proven to decrease colonisation on the surface of the skin, which is believed to decrease the risk of surgical site infection [7]. There was no standardised process across the hospital about when patients were informed of the requirement for preoperative CHG washes or how patients access the 4% CHG liquid or 2% CHG cloths needed to achieve this. Both CHG 4% liquid and CHG 2% cloths are recommended by the hospital although the liquid is predominately used as it more widely available and less costly. Some patients were provided with CHG wash by their surgeon at their preoperative consult whereas other patients were instructed via a phone call from the preadmissions team, to source their own CHG. For patients who received instructions via phone this often left little time for the patient to attempt to source the CHG needed as the phone calls often occurred the day or night before surgery was scheduled. It has been established in the literature that patient understanding of preoperative requirements and procedures is often poor which may affect compliance and patient safety [14]. This inconsistency in access and delivery of information led us to look at the patient experience of this process and to seek to obtain an understanding of how patients use CHG preoperatively and their understanding and experiences of this aspect of their care.
Patient’s experiences of preoperative washes
Methods The aim of this study was to gain an understanding of the patients’ experiences of the process of preoperative washing with CHG, patient compliance and patient understanding of the rationale for preoperative washes using CHG. The study utilised survey methods to investigate patients’ experiences and understanding of the use of CHG preoperatively. The researchers consulted with a biostatistician who advised no formal sample size calculations were required as the study was descriptive in nature. A survey was designed to capture the required data for this study with reference to literature in the area and the expertise of the preadmissions team who had knowledge of preoperative CHG practices at the study hospital and some of the issues patients experienced. The data for this study was captured via paper-based surveys distributed to inpatients who had undergone a surgical procedure at SJGSH. Adult patients from all surgical specialities were invited to participate in the survey over a ten week period from February to April 2016 (convenience sample). Participants were provided with an information letter, survey and an envelope to seal their completed survey in and return via internal mail. Potential participants were made aware that participation was voluntary and that their decision to participate or not participate would not impact on their care in anyway. The survey consisted of 17 questions: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.
16. 17.
Age Gender Type of Surgery Who told you about preoperative washing with chlorhexidine before your surgery? Were you provided with chlorhexidine wash before your admission to hospital? Were you instructed to buy your own chlorhexidine wash? If you needed to buy chlorhexidine were you able to find and purchase the required wash? If you need to buy chlorhexidine how difficult was it for you to find? Did you use chlorhexidine wash before your operation? How many times did you use the chlorhexidine wash before your operation? What type of wash did you use before your operation? Were the instructions to use the chlorhexidine wash easy to follow? I understood the reasons for using chlorhexidine wash before my operation: Fully/Mostly/A little/Not at all. In your own words explain the reasons for using chlorhexidine wash before surgery The amount of information I received about using chlorhexidine wash before surgery was: Too little/ Just right/Too much. If you didn’t use chlorhexidine wash before your operation please state why? Any other comments?
Sample and inclusion criteria Patients aged 18 years or over, who had been admitted to the study hospital for an inpatient surgical procedure and
53 could speak English were eligible to participate in the study. Patients who were under 18 years of age, patients who did not have a surgical procedure, patients who had dental surgery, patients who had eye surgery and nonEnglish speaking patients were excluded from the study.
Ethical concerns An application to undertake this study was submitted to the St John of God Health Care Research Ethics Committee (No: 919) and Curtin University Human Research Ethics Committee (HR05-2016). Potential participants were fully informed about the research via a participant information letter and consent was inferred through the completion and return of the survey.
Results In all 262 surveys were distributed to potential participants and a 74% (n Z 194) response rate was achieved. Of the surveys returned three were excluded from the final analysis, n Z 1 was returned blank and n Z 2 surveys were ineligible as the participants had surgical procedures listed in the exclusion criteria for the study. This left n Z 191 surveys which were suitable for analysis.
Demographics Of the 191 respondents, 190 provided responses to the demographic questions in the survey. There were respondents represented in all of the defined age categories with an age range of 19e93 years. There were more female respondents (59%, n Z 112) to the survey than male. Orthopaedic (16%, n Z 31) and neurosurgery (15%, n Z 28) were the most common surgical procedures although all other surgical specialities were represented (see Table 1).
Main results The majority of participants (50%, n Z 115) reported that they were informed about CHG washes by the
Table 1
Surgical speciality.
Surgical area
Frequency (n)
Percent (%)
Orthopaedics Neurosurgery Gynaecological Vascular Cardiac Obstetric General surgery Other Urology Colorectal ENT Plastics Unknown Gastroenterological
31 28 20 18 17 17 14 13 9 7 5 5 4 2
16% 15% 11% 9% 9% 9% 7% 7% 5% 4% 3% 3% 2% 1%
54
A.L. Cooper et al.
preadmissions team over the phone. A number of participants reported they were informed by the preadmissions team face to face (7%, n Z 15), while 21% (n Z 49) reported they were informed by a nurse and 11% (n Z 25) reported their surgeon informed them. Only 7% (n Z 15) reported that no-one informed them of CHG washes and 5% (n Z 11) of participants gained information from other sources including pharmacists, family and friends. This question format allowed participants to select more than one option, and in all 230 responses were given. The vast majority of participants (71%, n Z 135) were not provided with the CHG product prior to admission. These participants were then asked if they were instructed to buy their own CHG. Of the 108 participants that responded 71% (n Z 77) reported that they were instructed and 29% (n Z 31) that they had not been instructed. Most of the participants (94%, n Z 72) who were asked to buy CHG were able to purchase the required wash. Participants were instructed to purchase 4% CHG liquid from their local pharmacy. Only three of the participants who reported they had not received instructions to purchase CHG bought the wash, with two of the participants reporting they had known of the need to obtain CHG because of a previous surgery. All participants were asked if they used CHG before their operation. Of the 187 participants that responded 85% (n Z 159) reported that they had used CHG. A comparison of CHG usage and gender detected no differences. Participants that had used CHG prior to surgery were asked how many times they had used the wash. In total 160 participants responded to this question with 35% (n Z 56) using CHG once and 63% (n Z 101) using CHG twice. Most participants (88%, n Z 143) found the instructions to use CHG very or quite easy to follow while 9% (n Z 15) of participants reported that they didn’t read the instructions. Every participant was asked what type of wash they used. In total 185 participants responded to this question, with 82% (n Z 152) reporting using CHG 4% liquid wash. No participants reported using the 2% CHG cloths. The most common response of those who had not used CHG was that they used their usual soap or shower gel (12%, n Z 22). Participants were asked to rate their understanding of the reasons for using CHG and also to explain the reasons in their own words. In the 183 participants who responded understanding was rated highly with 94% (n Z 171) reporting they fully or mostly understood, with only 4% (n Z 8) reporting they had no understanding. This high level of understanding was reflected in the responses participants gave explaining the reasons for using CHG in their own words: “Chlorhexidine pre wash helps to reduce the microorganisms that live on healthy skin. So to disinfect the body before surgery” (Participant 186).
“As an antiseptic and antibacterial” (Participant 153).
“Prevent infection” (Participant 125). Eight participants didn’t know the reasons but had been instructed to use CHG:
“No idea no-one told me but I assume it was to remove nasty’s from the body” (Participant 171).
“Instructed by hospital staff” (Participant 169). Participants were also asked if they felt they had received the right amount of information about CHG washes. In total 177 participants responded to this question and 78% (n Z 138) felt the level of information they were given was just right. Conversely 20% (n Z 36) of participants felt they had received too little information and this was consistent across age groups (see Table 2). Participants who did not use CHG were asked to state the reasons why. The main reasons participants gave for not using CHG prior to surgery were, not being informed at all or being informed too late and not being able to find and purchase the CHG as a result. “I was only informed during a preadmission call the night before surgery, was too late” (Participant 141).
“I expected to be asked and provided with chlorhexidine wash. Nobody mentioned it” (Participant 114).
“I didn’t know it was required” (Participant 054). Finally, participants were given the opportunity to make any other comments, which elicited 67 responses. The key themes raised were a lack of information, issues with time or access and inconsistencies at the hospital. Lack of information “No information was given to me about the use of any preoperative body wash, the reason for their use or effects or consequences of use. I was handed a tube and asked to wash using the tube provided. I had three episodes of surgery Dec 15 e Feb 16” (Participant 161).
“The only reason I knew to use the soap is that I had another op at another hospital four weeks ago” (Participant 072).
Table 2
CHG information.
Age category
Too little
Just right
Too much
18e30 years 31e40 years 41e50 years 51e60 years 61e70 years 71e80 years 81e90 years 91e100 years
22% (n Z 2) 14% (n Z 4) 19% (n Z 4) 24% (n Z 6) 21% (n Z 10) 21% (n Z 7) 27% (n Z 3) 0% (n Z 0)
67% (n Z 6) 79% (n Z 22) 81% (n Z 17) 76% (n Z 19) 79% (n Z 37) 79% (n Z 26) 73% (n Z 8) 100% (n Z 2)
11% (n Z 1) 7% (n Z 2) 0% (n Z 0) 0% (n Z 0) 0% (n Z 0) 0% (n Z 0) 0% (n Z 0) 0% (n Z 0)
Patient’s experiences of preoperative washes Issues with time/access “I would have tried to purchase it if I had been given more notice” (Participant 136).
“It would have been good to know that I had to buy the special soap before the day before my surgery” (Participant 153).
“I would suggest patients are advised by the surgeon when booking the operation or provided with it direct by the surgeon at no charge. It’s not always easy to find and is the last thing one wants to be shopping for, in my case, late afternoon day before the operation” (Participant 059). Inconsistencies “For this operation I was admitted the day of the procedure e so need to buy the chlorhexidine wash. For a back operation in 2014 I was admitted the day before the procedure and was given the prewash prior to the procedure” (Participant 005).
“Chlorhexidine wash was provided when I was admitted as a maternity patient in 2013. In 2016 (for a different procedure) I was required to buy it myself. More notice (than the day before) would be appreciated as it was not that easy to find” (Participant 036).
Discussion The survey achieved a high response rate of 74% which is much higher than response rates usually achieved in patient populations [8]. We attribute this to 1) the time at which we elected to provide potential participants with the survey i.e. whilst they were postsurgical inpatients and had time to complete the questionnaire, 2) the approach whereby potential participants were invited to participate by a member of the research team and 3) the anonymity of the survey with returns in sealed envelopes via internal mail rather than directly handed back to researchers or other hospital staff. The wider adult inpatient surgical patient population in terms of gender in the financial year of 2015/2016 was 56% female and 44% male. This was similar to our sample of 59% female and 41% male. The most highly represented age group in the study sample was the 61e70 year old category which is slightly older than the average age of the adult surgical inpatient population in 2015/2016 which was 57 years old. The surgical specialities with the most inpatients in the financial year of 2015/2016 were orthopaedics and neurosurgery which were also the highest surgical areas in the study sample. A lower number of participants than expected reported that they were informed by the preadmissions team. This was in part because some participants had received
55 information face to face from the preadmissions team rather than over the phone as listed in the survey. It may also have been because some participants would not have distinguished between a nurse on the preadmissions team and other nurses. In hindsight the distinction between preadmissions nurses and ward nurses may have not been clear enough in the survey. As the survey was conducted in a private hospital it was expected that many patients would be required to source their own CHG given the cost implications to the organisation in providing CHG to all surgical patients. There are also logistical issues with many surgeons seeing patients preoperatively offsite, these patients cannot be provided with CHG or directed to purchase CHG from the hospital pharmacy at the time of their preoperative consult. However, the fact that almost a third of participants who were not provided with CHG reported that they were not instructed to purchase their own was unexpected. This may have been due to inaccuracies in self-reporting and participants not retaining information about CHG. Participants who reported they were instructed to buy their own CHG had high levels of compliance in obtaining the required wash. It would seem therefore that by increasing the number of patients who are informed the rate of CHG use would also increase. Participants who were instructed to buy CHG and given enough notice of this requirement found sourcing the required product on the whole straightforward. However, over a third of patients reported that they only used CHG once rather than the recommended two times. This may be due to some patients only using CHG on admission, immediately before their surgery, or only finding out about the requirement for CHG the night before surgery. Participants only using CHG once may not get the full potential benefits of preoperative bathing. The small proportion of patients that used CHG and did not read the instructions may also not have had optimum preoperative preparation due to incorrect usage of CHG. Insufficient, incorrect use and absence of use all have the potential to increase a patient’s risk of SSI [7]. Earlier notification which would be possible for elective surgery could help increase CHG use. Across all age groups 20% of participants felt they received too little information about CHG. This was echoed in the open-ended questions in which a number of participants either did not know the rationale as they were only instructed rather than informed or reported they had not been told about CHG at all. This lack of information some participants experienced is reflected in the numbers of participants who did not use or underused CHG. There is a clear potential to improve the level of information provided to all patients and subsequently increase the numbers of patients using CHG preoperatively and using it twice.
Limitations The results of this study are from a sample in a private hospital and may not be generalisable to patient populations in other settings. The data collected relied on self-reporting which in itself can be unreliable and inaccurate [2]. The sample size was small but representative of the study hospital population in terms of gender and surgical speciality.
56
Conclusion This project has revealed the current experience of patients undergoing surgery at the study hospital in relation to preoperative washing. Lack of information regarding CHG, issues with timing of information and access, as well as inconsistencies between different surgical specialities within the hospital were identified as barriers to participants using CHG. These are areas which could be targeted with a suite of interventions which aim to provide patients with clear, consistent information in a timely manner.
Conflict of interest No conflict of interest to declare.
Funding No funding was received for this study.
Acknowledgements We would like to thank the patients who participated in the study and Jo Halliday for her contribution in the initial stages of the project.
References [1] AORN. Guideline summary: preoperative patient skin antisepsis. AORN J 2015;101(1):81e4. http://dx.doi.org/10.1016/ j.aorn.2014.10.003. [2] Bhandari A, Wagner T. Self-reported utilization of health care services: improving measurement and accuracy. Med Care Res Rev 2006;63(2):217. [3] Bode LGM, Kluytmans JAJW, Wertheim HFL, Bogaers D, Vandenbroucke-Grauls CMJE, Roosendaal R, et al. Preventing surgical- site infections in nasal carriers of Staphylococcus aureus. N. Engl J Med 2010;362(1):9e17. http://dx.doi.org/10.1056/NEJMoa0808939.
A.L. Cooper et al. [4] Chien C-Y, Lin C-H, Hsu R-B. Care bundle to prevent methicillinresistant Staphylococcus aureus sternal wound infection after off-pump coronary artery bypass. Am J Infect Control 2014; 42(5):562e4. http://dx.doi.org/10.1016/j.ajic.2014.01.016. [5] Chlebicki MP, Safdar N, O’Horo JC, Maki DG. Preoperative chlorhexidine shower or bath for prevention of surgical site infection: a meta-analysis. Am J Infect Control 2013;41(2): 167e73. http://dx.doi.org/10.1016/j.ajic.2012.02.014. [6] Cruse PJ, Foord R. The epidemiology of wound infection: a 10year prospective study of 62,939 wounds. Surg Clin N. Am 1980;60(1):27e40. [7] Edmiston CE, Assadian O, Spencer M, Olmsted RN, Barnes S, Leaper D. To bathe or not to bathe with chlorhexidine gluconate: is it time to take a stand for preadmission bathing and cleansing? AORN J 2015;101(5):529e38. http: //dx.doi.org/10.1016/j.aorn.2015.02.008. [8] Johnson TP, Fullam F, VanGeest JB. Handbook of health survey methods Chapter 22 surveys of patient populations. 2014. p. 1340e97. http://dx.doi.org/10.1002/9781118594629.ch22. [9] Kamel C, McGahan L, Polisena J, Mierzwinski-Urban M, Embil J. Preoperative skin antiseptic preparations for preventing surgical site infections: a systematic review. Infect Control Hosp Epidemiol 2012;33:608e17. [10] Pofahl WE, Goettler CE, Ramsey KM, Cochran MK, Nobles DL, Rotondo MF. Active surveillance screening of MRSA and eradication of the carrier state decreases surgical-site infections caused by MRSA. J Am Coll Surg 2009;208(5):981e6. http: //dx.doi.org/10.1016/j.jamcollsurg.2008.12.025. [11] Rao N, Cannella BA, Crossett LS, Yates AJ, McGough RL, Hamilton CW. Preoperative screening/decolonization for Staphylococcus aureus to prevent orthopaedic surgical site infection: prospective cohort study with 2-year follow-up. J Arthroplast 2011; 26(8):1501e7. http://dx.doi.org/10.1016/j.arth.2011.03.014. [12] St John of God Subiaco Hospital. Pre-operative preparation. Policy number NCS 074. 2012. [13] Tanner J, Gould D, Jenkins P, Hilliam R, Mistry N, Walsh S. A fresh look at preoperative body washing. J Infect Prev 2012; 13(1):11e5. http://dx.doi.org/10.1177/1757177411428095. [14] Walker H, Thorn C, Omundsen M. Patients’ understanding of pre-operative fasting. Anaesth Intensive Care 2006;34(3):358. [15] Webster J, Osborne S. Pre-operative bathing or showering with skin antiseptics to prevent surgical site infection. Cochrane Database Syst Rev 2012;9. http: //dx.doi.org/10.1002/14651858.CD004985.pub4.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: http://www.journals.elsevier.com/infectiondisease-and-health/
Research
Exploring patient experience and understanding of Chlorhexidine Gluconate preoperative washes: A cross-sectional survey Alannah L. Cooper a,b,*, Janie A. Brown c, Julie Salathiel a, Sally Gollner a, Fiona Childs a, Elizabeth Boucher a, Danielle Morris a, Brian Riggall-Southworth a, Lyn Balinski a, Kaylene Riches a, Toni Dennis a, Felicity Timmings a a
St John of God Subiaco Hospital, Australia Fiona Stanley Hospital, Australia c Curtin University, Australia b
Received 6 January 2017; received in revised form 23 February 2017; accepted 23 February 2017
Available online 31 March 2017
KEYWORDS Patient care; Surgery; Chlorhexidine; Patient compliance; Survey
Abstract Objectives: To explore patient experience, understanding and compliance with using Chlorhexidine Gluconate (CHG) preoperative washes. Methods: A cross-sectional survey was conducted over a ten week period with adult inpatients who had undergone a surgical procedure at the study hospital. The survey consisted of 17 questions which participants self-completed. Closed and open-ended questions were included in the survey to allow both statistical and thematic analysis. Results: A 74% (n Z 194) sample response rate was attained. The sample obtained was representative of the wider hospital surgical patient population. Although 85% (n Z 159) of participants reported they used CHG prior to their surgical procedure only 63% (n Z 101) used the wash the recommended two times. Across all age groups in the survey 20% (n Z 36) of participants reported they received too little information about CHG washes. Open-ended questions revealed three key themes; lack of information, issues with time or access and inconsistencies across the hospital. Conclusion: This project revealed the current experience of patients undergoing surgery in relation to preoperative washing. Lack of information regarding CHG, issues with timing of information and access, as well as inconsistencies between different surgical specialities within
* Corresponding author. Nursing and Midwifery Research, St John of God Subiaco Hospital, 12 Salvado Road, Subiaco, Western Australian, 6008, Australia. E-mail address: [email protected] (A.L. Cooper). http://dx.doi.org/10.1016/j.idh.2017.02.002 2468-0451/ª 2017 Australasian College for Infection Prevention and Control. Published by Elsevier B.V. All rights reserved.
52
A.L. Cooper et al. the hospital were identified as barriers to participants using CHG. These are areas which could be targeted with a suite of interventions which aim to provide patients with clear, consistent information in a timely manner. ª 2017 Australasian College for Infection Prevention and Control. Published by Elsevier B.V. All rights reserved.
Highlights A cross-sectional survey of patient experience of CHG preoperative washes. Issues were discovered with the number of CHG applications, access, lack of information and understanding. By identifying issues patient’s encounter targeted interventions can be implemented to improve understanding and compliance.
Introduction
Background
Preoperative washing has been part of patient care for several decades and many research studies have been conducted examining the effectiveness of the various types of preoperative washes [6,7,13]. There has been a move away from recommending the use of CHG and other antiseptic washes with claims that the use of soap and water is equally effective [5,15], however the use of antiseptic washes remains commonplace [1,13]. Chlebicki et al. [5] conducted a meta-analysis which included 16 studies and found no appreciable benefit of CHG washes in the prevention of SSI. However, of the 16 studies included in the meta-analysis only four were published from 2009 onwards. The other 12 studies were published between 1979 and 1992 and as Chlebicki et al. [5] acknowledge most of the studies did not give details of a standardised process for CHG application and better designed trials are needed to determine the effectiveness of CHG on SSI rates. Systematic reviews synthesizing the results of recent research studies have debunked the claims of older studies that soap and water are just as effective at reducing bacterial colonisation as antiseptic washes [9]. Numerous recent studies have shown the effectiveness of CHG antiseptic washes in reducing SSI for and treatment of the colonisation of Staphylococcus aureus when used in conjunction with nasal screening [3,4,10,11]. Tanner et al. [13] raised concerns over UK national guidelines which did not support preoperative washing to reduce SSI and conducted a randomised control trial in healthy volunteers which demonstrated that CHG was significantly more effective than soap in reducing colony forming units. Similarly, Edmiston et al. [7] have raised the concern that organisations such as the Association of Perioperative Registered Nurses (AORN) and the Centers for Disease Control and Prevention (CDC) are basing recommendations on out-dated, methodologically weak research and not utilising evidence from more recent studies. These more recent studies which have a standardised process for CHG application demonstrate the potential benefits of CHG. A focus on how to facilitate the optimal use of CHG by patients as well as large scale randomised control trials with clear standardised processes are needed to determine the true effectiveness of CHG washes [7].
During the financial year of 2015/2016, 22,990 inpatient surgical procedures were performed at the study hospital. The study hospital policy states: “Where possible, elective surgical and obstetric patients (excluding paediatrics) should have at least (1) preoperative antiseptic shower prior to surgery, including hair washing if appropriate.” [12]; p. 3). Because the policy is vague and provides limited direction, it is standard care at the study hospital for the preadmission clinic to advise all patients admitted on the day of their elective surgery to undertake two preoperative CHG washes, one the night before surgery and one the morning of surgery. In addition to the verbal instructions around CHG washes a written instruction sheet is also emailed to patients. This measure was advised because preadmission clinic nurses were aware of the evidence reporting that CHG washes have been proven to decrease colonisation on the surface of the skin, which is believed to decrease the risk of surgical site infection [7]. There was no standardised process across the hospital about when patients were informed of the requirement for preoperative CHG washes or how patients access the 4% CHG liquid or 2% CHG cloths needed to achieve this. Both CHG 4% liquid and CHG 2% cloths are recommended by the hospital although the liquid is predominately used as it more widely available and less costly. Some patients were provided with CHG wash by their surgeon at their preoperative consult whereas other patients were instructed via a phone call from the preadmissions team, to source their own CHG. For patients who received instructions via phone this often left little time for the patient to attempt to source the CHG needed as the phone calls often occurred the day or night before surgery was scheduled. It has been established in the literature that patient understanding of preoperative requirements and procedures is often poor which may affect compliance and patient safety [14]. This inconsistency in access and delivery of information led us to look at the patient experience of this process and to seek to obtain an understanding of how patients use CHG preoperatively and their understanding and experiences of this aspect of their care.
Patient’s experiences of preoperative washes
Methods The aim of this study was to gain an understanding of the patients’ experiences of the process of preoperative washing with CHG, patient compliance and patient understanding of the rationale for preoperative washes using CHG. The study utilised survey methods to investigate patients’ experiences and understanding of the use of CHG preoperatively. The researchers consulted with a biostatistician who advised no formal sample size calculations were required as the study was descriptive in nature. A survey was designed to capture the required data for this study with reference to literature in the area and the expertise of the preadmissions team who had knowledge of preoperative CHG practices at the study hospital and some of the issues patients experienced. The data for this study was captured via paper-based surveys distributed to inpatients who had undergone a surgical procedure at SJGSH. Adult patients from all surgical specialities were invited to participate in the survey over a ten week period from February to April 2016 (convenience sample). Participants were provided with an information letter, survey and an envelope to seal their completed survey in and return via internal mail. Potential participants were made aware that participation was voluntary and that their decision to participate or not participate would not impact on their care in anyway. The survey consisted of 17 questions: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.
16. 17.
Age Gender Type of Surgery Who told you about preoperative washing with chlorhexidine before your surgery? Were you provided with chlorhexidine wash before your admission to hospital? Were you instructed to buy your own chlorhexidine wash? If you needed to buy chlorhexidine were you able to find and purchase the required wash? If you need to buy chlorhexidine how difficult was it for you to find? Did you use chlorhexidine wash before your operation? How many times did you use the chlorhexidine wash before your operation? What type of wash did you use before your operation? Were the instructions to use the chlorhexidine wash easy to follow? I understood the reasons for using chlorhexidine wash before my operation: Fully/Mostly/A little/Not at all. In your own words explain the reasons for using chlorhexidine wash before surgery The amount of information I received about using chlorhexidine wash before surgery was: Too little/ Just right/Too much. If you didn’t use chlorhexidine wash before your operation please state why? Any other comments?
Sample and inclusion criteria Patients aged 18 years or over, who had been admitted to the study hospital for an inpatient surgical procedure and
53 could speak English were eligible to participate in the study. Patients who were under 18 years of age, patients who did not have a surgical procedure, patients who had dental surgery, patients who had eye surgery and nonEnglish speaking patients were excluded from the study.
Ethical concerns An application to undertake this study was submitted to the St John of God Health Care Research Ethics Committee (No: 919) and Curtin University Human Research Ethics Committee (HR05-2016). Potential participants were fully informed about the research via a participant information letter and consent was inferred through the completion and return of the survey.
Results In all 262 surveys were distributed to potential participants and a 74% (n Z 194) response rate was achieved. Of the surveys returned three were excluded from the final analysis, n Z 1 was returned blank and n Z 2 surveys were ineligible as the participants had surgical procedures listed in the exclusion criteria for the study. This left n Z 191 surveys which were suitable for analysis.
Demographics Of the 191 respondents, 190 provided responses to the demographic questions in the survey. There were respondents represented in all of the defined age categories with an age range of 19e93 years. There were more female respondents (59%, n Z 112) to the survey than male. Orthopaedic (16%, n Z 31) and neurosurgery (15%, n Z 28) were the most common surgical procedures although all other surgical specialities were represented (see Table 1).
Main results The majority of participants (50%, n Z 115) reported that they were informed about CHG washes by the
Table 1
Surgical speciality.
Surgical area
Frequency (n)
Percent (%)
Orthopaedics Neurosurgery Gynaecological Vascular Cardiac Obstetric General surgery Other Urology Colorectal ENT Plastics Unknown Gastroenterological
31 28 20 18 17 17 14 13 9 7 5 5 4 2
16% 15% 11% 9% 9% 9% 7% 7% 5% 4% 3% 3% 2% 1%
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preadmissions team over the phone. A number of participants reported they were informed by the preadmissions team face to face (7%, n Z 15), while 21% (n Z 49) reported they were informed by a nurse and 11% (n Z 25) reported their surgeon informed them. Only 7% (n Z 15) reported that no-one informed them of CHG washes and 5% (n Z 11) of participants gained information from other sources including pharmacists, family and friends. This question format allowed participants to select more than one option, and in all 230 responses were given. The vast majority of participants (71%, n Z 135) were not provided with the CHG product prior to admission. These participants were then asked if they were instructed to buy their own CHG. Of the 108 participants that responded 71% (n Z 77) reported that they were instructed and 29% (n Z 31) that they had not been instructed. Most of the participants (94%, n Z 72) who were asked to buy CHG were able to purchase the required wash. Participants were instructed to purchase 4% CHG liquid from their local pharmacy. Only three of the participants who reported they had not received instructions to purchase CHG bought the wash, with two of the participants reporting they had known of the need to obtain CHG because of a previous surgery. All participants were asked if they used CHG before their operation. Of the 187 participants that responded 85% (n Z 159) reported that they had used CHG. A comparison of CHG usage and gender detected no differences. Participants that had used CHG prior to surgery were asked how many times they had used the wash. In total 160 participants responded to this question with 35% (n Z 56) using CHG once and 63% (n Z 101) using CHG twice. Most participants (88%, n Z 143) found the instructions to use CHG very or quite easy to follow while 9% (n Z 15) of participants reported that they didn’t read the instructions. Every participant was asked what type of wash they used. In total 185 participants responded to this question, with 82% (n Z 152) reporting using CHG 4% liquid wash. No participants reported using the 2% CHG cloths. The most common response of those who had not used CHG was that they used their usual soap or shower gel (12%, n Z 22). Participants were asked to rate their understanding of the reasons for using CHG and also to explain the reasons in their own words. In the 183 participants who responded understanding was rated highly with 94% (n Z 171) reporting they fully or mostly understood, with only 4% (n Z 8) reporting they had no understanding. This high level of understanding was reflected in the responses participants gave explaining the reasons for using CHG in their own words: “Chlorhexidine pre wash helps to reduce the microorganisms that live on healthy skin. So to disinfect the body before surgery” (Participant 186).
“As an antiseptic and antibacterial” (Participant 153).
“Prevent infection” (Participant 125). Eight participants didn’t know the reasons but had been instructed to use CHG:
“No idea no-one told me but I assume it was to remove nasty’s from the body” (Participant 171).
“Instructed by hospital staff” (Participant 169). Participants were also asked if they felt they had received the right amount of information about CHG washes. In total 177 participants responded to this question and 78% (n Z 138) felt the level of information they were given was just right. Conversely 20% (n Z 36) of participants felt they had received too little information and this was consistent across age groups (see Table 2). Participants who did not use CHG were asked to state the reasons why. The main reasons participants gave for not using CHG prior to surgery were, not being informed at all or being informed too late and not being able to find and purchase the CHG as a result. “I was only informed during a preadmission call the night before surgery, was too late” (Participant 141).
“I expected to be asked and provided with chlorhexidine wash. Nobody mentioned it” (Participant 114).
“I didn’t know it was required” (Participant 054). Finally, participants were given the opportunity to make any other comments, which elicited 67 responses. The key themes raised were a lack of information, issues with time or access and inconsistencies at the hospital. Lack of information “No information was given to me about the use of any preoperative body wash, the reason for their use or effects or consequences of use. I was handed a tube and asked to wash using the tube provided. I had three episodes of surgery Dec 15 e Feb 16” (Participant 161).
“The only reason I knew to use the soap is that I had another op at another hospital four weeks ago” (Participant 072).
Table 2
CHG information.
Age category
Too little
Just right
Too much
18e30 years 31e40 years 41e50 years 51e60 years 61e70 years 71e80 years 81e90 years 91e100 years
22% (n Z 2) 14% (n Z 4) 19% (n Z 4) 24% (n Z 6) 21% (n Z 10) 21% (n Z 7) 27% (n Z 3) 0% (n Z 0)
67% (n Z 6) 79% (n Z 22) 81% (n Z 17) 76% (n Z 19) 79% (n Z 37) 79% (n Z 26) 73% (n Z 8) 100% (n Z 2)
11% (n Z 1) 7% (n Z 2) 0% (n Z 0) 0% (n Z 0) 0% (n Z 0) 0% (n Z 0) 0% (n Z 0) 0% (n Z 0)
Patient’s experiences of preoperative washes Issues with time/access “I would have tried to purchase it if I had been given more notice” (Participant 136).
“It would have been good to know that I had to buy the special soap before the day before my surgery” (Participant 153).
“I would suggest patients are advised by the surgeon when booking the operation or provided with it direct by the surgeon at no charge. It’s not always easy to find and is the last thing one wants to be shopping for, in my case, late afternoon day before the operation” (Participant 059). Inconsistencies “For this operation I was admitted the day of the procedure e so need to buy the chlorhexidine wash. For a back operation in 2014 I was admitted the day before the procedure and was given the prewash prior to the procedure” (Participant 005).
“Chlorhexidine wash was provided when I was admitted as a maternity patient in 2013. In 2016 (for a different procedure) I was required to buy it myself. More notice (than the day before) would be appreciated as it was not that easy to find” (Participant 036).
Discussion The survey achieved a high response rate of 74% which is much higher than response rates usually achieved in patient populations [8]. We attribute this to 1) the time at which we elected to provide potential participants with the survey i.e. whilst they were postsurgical inpatients and had time to complete the questionnaire, 2) the approach whereby potential participants were invited to participate by a member of the research team and 3) the anonymity of the survey with returns in sealed envelopes via internal mail rather than directly handed back to researchers or other hospital staff. The wider adult inpatient surgical patient population in terms of gender in the financial year of 2015/2016 was 56% female and 44% male. This was similar to our sample of 59% female and 41% male. The most highly represented age group in the study sample was the 61e70 year old category which is slightly older than the average age of the adult surgical inpatient population in 2015/2016 which was 57 years old. The surgical specialities with the most inpatients in the financial year of 2015/2016 were orthopaedics and neurosurgery which were also the highest surgical areas in the study sample. A lower number of participants than expected reported that they were informed by the preadmissions team. This was in part because some participants had received
55 information face to face from the preadmissions team rather than over the phone as listed in the survey. It may also have been because some participants would not have distinguished between a nurse on the preadmissions team and other nurses. In hindsight the distinction between preadmissions nurses and ward nurses may have not been clear enough in the survey. As the survey was conducted in a private hospital it was expected that many patients would be required to source their own CHG given the cost implications to the organisation in providing CHG to all surgical patients. There are also logistical issues with many surgeons seeing patients preoperatively offsite, these patients cannot be provided with CHG or directed to purchase CHG from the hospital pharmacy at the time of their preoperative consult. However, the fact that almost a third of participants who were not provided with CHG reported that they were not instructed to purchase their own was unexpected. This may have been due to inaccuracies in self-reporting and participants not retaining information about CHG. Participants who reported they were instructed to buy their own CHG had high levels of compliance in obtaining the required wash. It would seem therefore that by increasing the number of patients who are informed the rate of CHG use would also increase. Participants who were instructed to buy CHG and given enough notice of this requirement found sourcing the required product on the whole straightforward. However, over a third of patients reported that they only used CHG once rather than the recommended two times. This may be due to some patients only using CHG on admission, immediately before their surgery, or only finding out about the requirement for CHG the night before surgery. Participants only using CHG once may not get the full potential benefits of preoperative bathing. The small proportion of patients that used CHG and did not read the instructions may also not have had optimum preoperative preparation due to incorrect usage of CHG. Insufficient, incorrect use and absence of use all have the potential to increase a patient’s risk of SSI [7]. Earlier notification which would be possible for elective surgery could help increase CHG use. Across all age groups 20% of participants felt they received too little information about CHG. This was echoed in the open-ended questions in which a number of participants either did not know the rationale as they were only instructed rather than informed or reported they had not been told about CHG at all. This lack of information some participants experienced is reflected in the numbers of participants who did not use or underused CHG. There is a clear potential to improve the level of information provided to all patients and subsequently increase the numbers of patients using CHG preoperatively and using it twice.
Limitations The results of this study are from a sample in a private hospital and may not be generalisable to patient populations in other settings. The data collected relied on self-reporting which in itself can be unreliable and inaccurate [2]. The sample size was small but representative of the study hospital population in terms of gender and surgical speciality.
56
Conclusion This project has revealed the current experience of patients undergoing surgery at the study hospital in relation to preoperative washing. Lack of information regarding CHG, issues with timing of information and access, as well as inconsistencies between different surgical specialities within the hospital were identified as barriers to participants using CHG. These are areas which could be targeted with a suite of interventions which aim to provide patients with clear, consistent information in a timely manner.
Conflict of interest No conflict of interest to declare.
Funding No funding was received for this study.
Acknowledgements We would like to thank the patients who participated in the study and Jo Halliday for her contribution in the initial stages of the project.
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